Archives of Surgery

doi: 10.1001/archsurg.1989.01410110009001pmid: N/A

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Roses, Daniel F.;Karp, Nolan S.;Sudarsky, Laura A.;Valensi, Quentin J.;Rosen, Robert J.;Blum, Manfred

doi: 10.1001/archsurg.1989.01410110015002pmid: 2818176

Abstract • An increasingly recognized although small percentage of patients with primary hyperparathyroidism have enlargement of two parathyroid glands. We have treated nine patients with primary hyperparathyroidism associated with such double parathyroid gland enlargement. In four of these patients, marked asymmetry of the two enlarged glands was noted and the failure to recognize and excise a second enlarged parathyroid gland resulted in persistent or recurrent hyperparathyroidism. In one of these patients, the second enlargement was present in a supernumerary mediastinal gland. The subsequent excision of the second enlarged parathyroid gland resulted in normocalcemia in each instance. This contrasts with five patients in whom initial excision of two enlarged glands resulted in normocalcemia with no recurrence of hypercalcemia. Only three patients fulfilled the histologic criteria of true double adenomas. The remainder showed multiglandular hypercellularity. This experience supports identifying all parathyroid glands and recognizing that even minimal enlargement of a gland may be important pathophysiologically, regardless of its histopathologic classification. Excision of both enlarged glands, even if asymmetric, is appropriate. (Arch Surg. 1989;124:1261-1265) References 1. Churchill ED. Cited by: Bauer W, Federman DD. Hyperparathyroidism epitomized: the case of Captain Charles E. Martell . Metabolism . 1962;11:21-29. 2. Harness JK, Ramsburg SR, Nishiyama RH, Thompson NW. Multiple adenomas of the parathyroids: do they exist? Arch Surg . 1978;114:468-474.Crossref 3. Verdonk CA, Edis AJ. Parathyroid 'double adenomas': fact or fiction? Surgery . 1981;90:523-526. 4. Bruining HA, Birkenhager MD, Ong GL, Lamberts SWJ. Causes of failure in operations for hyperparathyroidism . Surgery . 1987;101:562-565. 5. Wells SA, Leight GS, Hensley M, Dilley WG. Hyperparathyroidism associated with the enlargement of two or three parathyroid glands . Ann Surg . 1985;202:533-538.Crossref 6. Farnebo L, Trigonis C, Forsgen L, Granberg P, Hamberger B. Surgery for primary hyperparathyroidism . Acta Chir Scand . 1984;520:11-16. 7. Wang CA, Rieder SV. A density test for the intraoperative differentiation of parathyroid hyperplasia from neoplasia . Ann Surg . 1978;187:63-67.Crossref 8. Harrison TS, Duarte B, Reitz RE, et al. Primary hyperparathyroidism: four- to eight-year postoperative followup demonstrating persistent functional insignificance of microscopic parathyroid hyperplasia and decreased anatomy of parathyroid hormone release . Ann Surg . 1981;194:429-437.Crossref 9. Wang CA. The anatomic basis of parathyroid surgery . Ann Surg . 1976;183:271-275.Crossref 10. Edis AJ, Beahrs OH, van Heerden JA, Akari OE. 'Conservative' versus 'liberal' approach to parathyroid neck exploration . Surgery . 1977;82:466-473 11. Rasbach DA, Monchik J, Geelhoed GW, Harrison TS. Solitary parathyroid microadenoma . Surgery . 1984;96:1092-1097. 12. Liechty RD, Teter A, Suba EJ. The tiny parathyroid adenoma . Surgery . 1986;100:1048-1052. 13. Monchick JM, Farrugia R, Teplitz C, Teplitz J, Brown S. Parathyroid surgery: the role of chief cell intracellular fat staining with osmium carmine in the intraoperative management of patients with primary hyperparathyroidism . Surgery . 1983;94:877-886. 14. Saffos RO, Rhatigan RM, Urugulu S. The normal parathyroid and the borderline with early hyperplasia: a light microscopic study . Histopathology . 1984;8:407-422.Crossref 15. Gilmour JP. The gross anatomy of the parathyroid glands . J Pathol Bacteriol . 1938;46:133-149.Crossref 16. Russell JF, Grant CS, van Heerden JA. Hyperfunctioning supernumerary parathyroid glands, an occasional cause of hyperparathyroidism . Mayo Clin Proc . 1982;57:121-124. 17. Palmer JA, Sutton FR. Importance of a fifth parathyroid gland in the surgical treatment of hyperparathyroidism . Can J Surg . 1978;21:350-351. 18. Wang CA, Mahaffey JE, Axelrod L, Perlman JA. Hyperfunctioning supernumerary parathyroid glands . Surg Gynecol Obstet . 1979;148:711-714. 19. Doppman JL, Wells SA, Shimkin PM, et al. Parathyroid localization by angiographic techniques in patients with previous neck surgery . Br J Radiol . 1973;46:403-418.Crossref 20. Doppman JL, Marx SJ, Brennan MF, Beazley RM, Geelhoed G, Aurbach GD. The blood supply of mediastinal parathyroid adenomas . Ann Surg . 1977;185:488-490.Crossref 21. Roses DF, Sudarsky LA, Sanger J, Raghavendra BH, Reede DL, Blum M. The use of preoperative localization of adenomas of the parathyroid glands by thallium-technetium subtraction scintigraphy, high-resolution ultrasonography and computed tomography . Surg Gynecol Obstet . 1989;108:99-106. 22. Miller DL, Doppman JL, Shawker TH, et al. Localization of parathyroid adenomas in patients who have undergone surgery, I: noninvasive imaging methods . Radiology . 1987;162:133-137.Crossref 23. Miller DL, Doppman JL, Krudy AG, et al. Localization of parathyroid adenomas in patients who have undergone surgery, II: invasive procedures . Radiology . 1987;162:138-141.Crossref 24. Nussbaum SR, Thompson AR, Hutcheson KP, Gaz RD, Wang C. Intraoperative measurement of parathyroid hormone in the surgical management of hyperparathyroidism . Surgery . 1988;104:1121-1127. 25. Darling GE, Marx SJ, Spiegel AM, Aurbach GD, Norton JA. Prospective analysis of intraoperative and postoperative urinary cyclic adenosine 3',5'-monophosphate levels to predict outcome of patients undergoing reoperations for primary hyperparathyroidism . Surgery . 1988;104:1128-1136.

Haffty, Bruce G.;Goldberg, Neal B.;Rose, Marie;Heil, Barbara;Fischer, Diana;Beinfield, Malcolm;McKhann, Charles;Weissberg, Joseph B.

doi: 10.1001/archsurg.1989.01410110020003pmid: 2818177

Abstract • Conservative surgery and radiation therapy have been increasingly utilized at Yale–New Haven (Conn) Hospital since the 1960s. This analysis represents our experience from 1962 to 1982, with a total of 281 patients having a minimum assessable follow-up of five years and a median follow-up of 7.4 years. Five- and ten-year actuarial survivals were 83% and 67%, respectively. The actuarial breast recurrence-free rate was 91% at five years and 80% at ten years. Of 31 patients having recurrences in the breast alone, the actuarial five-year survival following recurrence was 48%. Twenty-eight (90%) of these 31 recurrences were salvageable with mastectomy or repeated wedge resection. Patients experiencing an early breast recurrence (less than three years) following initial treatment had a poorer prognosis than patients having recurrences later. (Arch Surg 1989;124:1266-1270) References 1. Fisher B, Bauer M, Margolese R, et al: Five-year results of randomized clinical trial comparing total mastectomy and segmental mastectomy with or without radiation in the treatment of early breast cancer . N Engl J Med 1985;312:665-673.Crossref 2. Calle R, Vilcoq JR, Zafrani B, et al: Local control and survival of breast cancer treated by limited surgery followed by irradiation . Cancer 1986;12:873-876. 3. Delouche G, Bachelot F, Premount M, et al: Conservative treatment of early breast cancer: Long-term results and complications . Int J Radiat Oncol Biol Phys 1987;13:29-34.Crossref 4. Recht A, Silver B, Schnitt S, et al: Breast relapse following primary radiation therapy for early breast cancer: I. Classification, frequency, and salvage . Int J Radiat Oncol Biol Phys 1985;11:1271-1276.Crossref 5. Fisher B, Wolmark N: Conservative surgery: The American experience . Semin Oncol 1986;13:425-438. 6. Veronesi U, Saccozzi R, DelVecchio M, et al: Comparing radical mastectomy with quadrantectomy, axillary dissection, and radiotherapy in patients with small cancers of the breast . N Engl J Med 1981;305:6-11.Crossref 7. Sarrazin D, Le M, Rouesse J, et al: Conservative treatment versus mastectomy in breast cancer tumors with macroscopic diameter of 20 millimeters or less: The experience of the Institut Gustave-Roussy . Cancer 1984;53:1209-1213.Crossref 8. Kurtz JM, Amalric R, DeLouche G, et al: The second ten years: Longterm risks of breast conservation , abstracted. Int J Radiat Oncol Biol Phys 1985;11( (suppl 1) ):184. 9. Schnitt S, Connolly J, Recht A, et al: Breast relapse following primary radiation therapy for early breast cancer: II. Detection, pathologic features, and prognostic significance . Int J Radiat Oncol Biol Phys 1985;11:1277-1284.Crossref 10. Clarke DH, Le MG, Sarrazin D, et al: Analysis of local-regional relapses in patients with early breast cancers treated by excision and radiotherapy: Experience of the Institut Gustave-Roussy . Int J Radiat Oncol Biol Phys 1985;11:137-145.Crossref 11. Harris JR, Recht A, Amalric R, et al: Time course and prognosis of local recurrence following primary radiation therapy for early breast cancer . J Clin Oncol 1984;2:37-41. 12. Kurtz JM, Spitalier JM, Amalric R: Late breast recurrence after lumpectomy and irradiation . Int J Radiat Oncol Biol Phys 1983;9:1191-1194.Crossref 13. Mate TM, Carter D, Fischer D, et al: A clinical and histopathologic analysis of the results of conservative surgery and radiation therapy in stage I and II breast cancer . Cancer 1986;58:1995-2002.Crossref 14. Kurtz JM, Amalric R, Brandone KT: A second chance to preserve the breast: Results of wide excision for breast recurrence after lumpectomy and irradiation , abstracted. Int J Radiat Oncol Biol Phys 1985, (suppl 1) , p 103.

Corbally, Martin T.;McAnena, Oliver;Urmacher, Carlos;Herman, Bob;Shiu, Man H.

doi: 10.1001/archsurg.1989.01410110025004pmid: 2818178

Abstract • A retrospective study of 19 patients with pancreatic cystadenoma included 15 patients with microcystic and 4 with mucinous cystadenomas. The typical clinical presentation was that of an elderly woman with an upper abdominal mass. An association with diabetes mellitus and extrapancreatic malignant disease was noted. Total tumor resection provided the best chance of cure and removed the risk of compression of adjacent organs and, in mucinous cystadenomas, the risk of malignant transformation. (Arch Surg. 1989;124:1271-1274) References 1. Piper CE, ReMine WH, Priestley JT. Pancreatic cystadenoma . JAMA . 1962;180:648-652.Crossref 2. Abrams RH, Berenbaum ER, Berenbaum SL, Ngo NL. Benign and malignant cystadenoma . Radiology . 1967;89:1028-1032.Crossref 3. Kerlin DL, Frey CF, Bodai BI, Twomey PL, Ruebner B. Cystic neoplasms of the pancreas . Surg Gynecol Obstet . 1987;165:475-478. 4. Friedman AC, Lichenstein JE, Dachman AH. Cystic neoplasms of the pancreas: radiological-pathological correlation . Radiology . 1983;149:45-50.Crossref 5. Cubilla AL, Fitzgerald PJ. Tumors of the exocrine pancreas . In: Atlas of Tumor Pathology . Washington, DC: Armed Forces Institute of Pathology; 1984;19( (pt 2) ):100-101. 6. Compagno J, Oertel JE. Mucinous cystic neoplasms of the pancreas with overt and latent malignancy: a clinicopathologic study of 41 cases . Am J Clin Pathol . 1978;69:573-580. 7. Hodgkinson DJ, ReMine WH, Weiland LH. Pancreatic cystadenoma: a clinicopathological study of 45 cases . Arch Surg . 1978;113:512-519.Crossref 8. Zamora JL, Gunn LC, Manaligod JR. Microcystic adenoma of the pancreas: a newly recognized benign lesion . Curr Surg . 1984;41:448-452. 9. Von Segesser L, Rohner A. Pancreatic cystadenoma and cystadenocarcinoma . Br J Surg . 1984;71:449-451.Crossref 10. Soloway HB. Constitutional abnormalities associated with pancreatic cystadenomas . Cancer . 1965;18:1297-1300.Crossref 11. Didolkar MS, Holyode ED. Cystadenoma of the pancreas . Surg Gynecol Obstet . 1975;140:925-928. 12. Compagno J, Oertel JE. Microcystic adenomas of the pancreas: a clinicopathological study of 34 cases . Am J Clin Pathol . 1978;69:289-298. 13. Hyde GL, Davis JB Jr, McMillin RD, et al. Mucinous cystic neoplasm of the pancreas with latent malignancy . Ann Surg . 1984;50:225-229. 14. Yu HC, Shetty J. Mucinous cystic neoplasm of the pancreas with high carcinoembryonic antigen . Arch Pathol Lab Med . 1985;109:375-377. 15. Tatsuta M, Iishi H, Ichii M, Noguchi S, Yamamoto R, Yamamura H. Values of carcinoembryonic antigen, elastase 1, and carbohydrate antigen determinant in aspirated pancreatic cystic fluid in the diagnosis of cysts of the pancreas . Cancer . 1986;57:1836-1839.Crossref

Fortner, Joseph G.;Vitelli, Carlo E.;Maclean, Barbara

doi: 10.1001/archsurg.1989.01410110029005pmid: 2818179

Abstract • Fifty-two consecutive patients with proximal extrahepatic bile duct tumors were treated by one of us (J.G.F.) between 1974 and 1987 at Memorial Sloan-Kettering Cancer Center, New York, NY. Thirty-eight patients (73%) underwent palliative procedures aimed at relieving the biliary obstruction (group A) and 14 patients (27%) were operated on with curative intent (group B). The choice of the surgical procedure employed to relieve the biliary obstruction did not significantly influence the length of survival of patients in group A in whom the median survival was 13.5 months and the in-hospital mortality was 15.7%. Fifty percent of the patients in group B underwent major liver resections to macroscopically encompass the tumor. In this group, although 35% of the patients experienced major complications, no inhospital mortalities were encountered and the median actuarial survival was 38 months. The projected and crude 5-year survival rates were 28% and 21%, respectively. Age, gender, extent of resection, microscopic status of margins of resection, and grade of the lesion did not affect the length of survival in patients in group B. Locoregional failure, either isolated or as a component of peritoneal failure, was detected in the 6 patients in whom the disease has recurred. Eighty-three percent of the patients in whom the disease has recurred were dead within 12 months of the diagnosis of recurrence. Two long-term survivors (14%) developed second primary tumors in the follow-up period. (Arch Surg. 1989;143:1275-1279) References 1. Longmire WP Jr. Tumors of the extrahepatic biliary radicles . Curr Probi Cancer . 1976;1:1-35.Crossref 2. Silverberg E, Lubera J. Cancer statistics 1987 . CA . 1987;37:2-19. 3. Fortner JG, Kallum BT, Kim DK, Hermann RE. Surgical management of carcinoma at the junction of the main hepatic ducts . Ann Surg . 1976;184:68-72.Crossref 4. Lees CD, Zapolanski A, Cooperman AM. Carcinoma of the bile ducts . Surg Gynecol Obstet . 1980;151:193-198. 5. Mittal B, Deutsch M, Iwatsuki J. Primary cancers of the extrahepatic biliary passages . Int J Radiat Oncol Biol Phys . 1985;11:849-854.Crossref 6. Ottow RT, Sugarbaker PH, August DA. Treatment of proximal biliary duct carcinoma: an overview of techniques and results . Surgery . 1985;97:251-262. 7. Praderi RC, Estefan AF, Triscornia E. Transhepatic intubation in benign and malignant lesions of the biliary ducts . Curr Probl Surg . 1985;22:3-66.Crossref 8. Terblanche J, Saunders SJ, Louw JH. Prolonged palliation in carcinoma of the main hepatic duct junction . Surgery . 1972;71:720-731. 9. Beazley RM, Hadjis N, Benjamin IS, Blumgart LH. Clinicopathological aspects of high bile duct cancer . Ann Surg . 1984;199:623-636.Crossref 10. Bengmark S, Ekberg H, Evander A, Klöfver-Stahl B, Tranberg KG. Major liver resection for hilar cholangiocarcinoma . Ann Surg . 1988;207:120-125.Crossref 11. Bismuth H, Castaing D, Traynor O. Resection or palliation priority of surgery in the treatment of hilar cancer . World J Surg . 1988;12:39-47.Crossref 12. Bruggen JT, Mcphee MS, Bathia PS, Richter JM. Primary adenocarcinoma of the bile ducts . Dig Dis Sci . 1986;31:840-846.Crossref 13. Evander A, Fredlund P, Hoevels J, Ihse I, Bengmark S. Evaluation of aggressive surgery for carcinoma of extrahepatic ducts . Ann Surg . 1980;191:23-29.Crossref 14. Lai ECS, Tompkins RK, RoslynJJ, Mann LL. Proximal bile duct cancer . Ann Surg . 1987;205:111-118.Crossref 15. Langer JC, Langer B, Taylor BR, Zeldin R, Cummings B. Carcinoma of the extrahepatic bile ducts: results of an aggressive surgical approach . Surgery . 1985;98:752-759. 16. Lygidakis NJ, Van der Hyde MN. Surgical approaches for unresectable primary carcinoma of the hepatic hilum . Surg Gynecol Obstet . 1988;166:107-114. 17. Mizumoto R, Kawarada Y, Suzuki H. Surgical treatment of hilar carcinoma of the bile ducts . Surg Gynecol Obstet . 1986;162:153-158. 18. Pichlmayr R, Ringe B, Lauchart W, Bechstein WO, Gubernatis G, Wagner E. Radical resection and liver grafting as the two main components of surgical strategy in the treatment of PBDT . World J Surg . 1988;12:68-77.Crossref 19. Tsuzuki T, Ogata Y, Iida S, Nakanishi I, Takinaka Y, Yoshii H. Carcinoma of the bifurcation of the hepatic ducts . Arch Surg . 1983;118:1147-1151.Crossref 20. White TT. Skeletonization and central hepatic resection in the treatment of bile duct cancer . World J Surg . 1988;12:48-51.Crossref 21. Pinson CW, Rossi RL. Extended right lobectomy, left hepatic lobectomy and skeletonization resection for proximal bile duct cancer . World J Surg . 1988;12:52-59.Crossref 22. Kaplan EL, Meier P. Non parametric estimation from incomplete observations . J Am Stat Assoc . 1958;53:457-481.Crossref 23. Black K, Hanna SS, Langer B, Jirsch DW, Rider WD. Management of carcinoma of extrahepatic bile ducts . Can J Surg . 1978;21:541-545. 24. Den Besten L, Liechty RD. Cancer of the biliary tree . Am J Surg . 1965;109:412-419. 25. Kuwayti K, Baggenstoss AH, Stauffer MH, Priestley JT. Carcinoma of the major intra and extrahepatic bile ducts exclusive of the papilla of Vater . Surg Gynecol Obstet . 1957;104:357-366. 26. Fletcher MS, Brinkley D, Hoevels J, Dawson JL, Nunnerley H. Treatment of hilar cholangiocarcinoma by drainage combined with internal radiotherapy using Iridium 192 wire . Br J Surg . 1983;70:733-735.Crossref 27. Iwatsuki S, Gordon GD, Shaw BW, Starzl TE. The role of liver transplantation in cancer therapy . Ann Surg . 1985;202:401-407.Crossref 28. Hadjis NS, Collier NA, Blumgart LH. Malignant masquerade at the hilum of the liver . Br J Surg . 1985;72:659-661.Crossref 29. Blumgart LH, Thompson JN. The management of malignant strictures of the bile ducts . Curr Probl Surg . 1987;24:69-127. 30. Gibson RN, Yeung E, Thompson JN, et al. Bile duct obstruction: radio-logic evaluation of level, cause and tumor resectability . Radiology . 1986;160:43-47.Crossref 31. Baron RL, Stanley RJ, Lee KT, et al. A prospective comparison of the evaluation of biliary strictures using CT and US . Radiology . 1982;145:91-98.Crossref 32. Pitt HA, Gomes AS, Mann LL, Deutsch LS, Longmire WP. Does preoperative PBD reduce operative risk or increase hospital cost? Ann Surg . 1985;201:545-551.Crossref 33. McPherson GAD, Benjamin IS, Hogdson HJF, Bowley NB, Allison DJ, Blumgart LH. Preoperative PBD: the results of a controlled trial . Br J Surg . 1984;71:371-374.Crossref 34. Sakaguchi S, Nakamura S. Surgery of the portal vein in resection of cancer of the hepatic hilus . Surgery . 1986;99:344-349. 35. Fortner JG, Kim DK, Cubilla A, Turnbull A, Pahnke LD, Shils ME. Regional pancreatectomy . Ann Surg . 1977;186:42-50.Crossref 36. Fortner JG, Shiu MH, Kinne DW, et al. Major hepatic resection using vascular isolation and hypothermic perfusion . Ann Surg . 1974;180:644-652.Crossref 37. Fields JN, Enami B. Carcinoma of the extrahepatic biliary system: results of primary and adjuvant radiotherapy . Int J Radiat Oncol Biol Phys . 1987;13:331-338.Crossref 38. Kopelson G, Galbadini J, Warshaw AL, Gunderson LL. Patterns of failure after curative resection for extrahepatic biliary tract carcinoma: implications for adjuvant therapy . Int J Radiat Oncol Biol Phys . 1981;7:413-417.Crossref 39. Iwasaki Y, Todoroki T, Fukao K, Ohara K, Okamura T, Nishimura A. The role of intraoperative radiotherapy in the treatment of bile duct cancer . World J Surg . 1988;12:91-98.Crossref 40. Molt P, Hopfan S, Watson RC, Botet JF, Brennan MF. Intraluminal radiation therapy in the management of malignant biliary obstruction . Cancer . 1986;57:536-544.Crossref 41. Todoroki T, Iwasaki Y, Okamura T, et al. Intraoperative radiotherapy for advanced carcinoma of the biliary system . Cancer . 1980;46:2179-2184.Crossref 42. Obenfield RA, Rossi RL. The role of chemotherapy in the treatment of bile duct cancer . World J Surg . 1988;123:105-108.Crossref 43. Tompkins RK, Thomas D, Wile A, Longmire WP. Prognostic factors in bile duct carcinoma . Ann Surg . 1981;194:447-457.Crossref

Dougherty, Steve H.;Saltzstein, Edward C.;Peacock, Jack B.;Mercer, Leo C.;Cano, Pearl

doi: 10.1001/archsurg.1989.01410110034006pmid: 2818180

Abstract • To study the influence of bacterial culture data on the clinical management of gangrenous or perforated appendicitis, we reviewed records of 104 patients who had been treated empirically with aminoglycoside antibiotics. Culture results appeared to influence antibiotic therapy in only 7 patients (7%). The routine cultures obtained at appendectomy affected therapy in only 2 patients. Discriminant analysis identified postoperative infectious complications and related factors as the principal determinants of culture utility. We conclude that, in patients with perforated appendicitis treated empirically with aminoglycoside combination regimens, culture results were seldom used for clinical management except in instances of postoperative infectious complication. Routine cultures and Gram's stains of perforated appendicitis, however, should still be obtained (1) to allow epidemiologic tracking in the hospital; (2) to identify organisms that are recovered infrequently but may cause serious disease (eg, Clostridium); and (3) because newer antibiotics are replacing aminoglycosides in the treatment of perforated appendicitis. (Arch Surg. 1989;124:1280-1283) References 1. Matlow A, Bohnen J. Are intra-operative cultures useful in abdominal surgery? In: Program and abstracts of the 24th Interscience Conference on Antimicrobial Agents and Chemotherapy; October 24, 1984; Washington, DC. 2. Cooksey RC. Probes for beta-lactamase: are they useful? Read before the 27th Interscience Conference on Antimicrobial Agents and Chemotherapy; October 6, 1987; New York, NY. 3. Brook I. Bacterial studies of peritoneal cavity and postoperative surgical wound drainage following perforated appendix in children . Ann Surg . 1980:192:208-212.Crossref 4. Marchildon MB, Dudgeon DL. Perforated appendix: current experience in a children's hospital . Ann Surg . 1977;185:84-87.Crossref 5. Lorber B, Swenson RM. The bacteriology of intra-abdominal infections . Surg Clin North Am . 1975;55:1349-1354. 6. Stone HH, Kolb LD, Geheber CE. Incidence and significance of intraperitoneal bacteria . Ann Surg . 1975;181:705-715.Crossref 7. Gorbach SL, Thadepalli H, Norsen J. Anaerobic microorganisms in intraabdominal infections . In: Balows A, DeHann RH, Dowell VR, Guze LB, eds. Anaerobic Bacteria: Role in Disease . Springfield, Ill: Charles C Thomas Publisher; 1974:339. 8. Elmore JR, Dibbins AW, Curci MR. The treatment of complicated appendicitis in children . Arch Surg . 1987;122:424-427.Crossref 9. Samelson SL, Reyes HM. Management of perforated appendicitis in children: revisited . Arch Surg . 1987;122:691-696.Crossref 10. Stafford ES, Sprong DH Jr. The mortality from acute appendicitis in The Johns Hopkins Hospital . JAMA . 1940;115:1242-1245.Crossref 11. Barnes BA, Behringer GE, Wheelock FC, Wilkins EW. Treatment of appendicitis at the Massachusetts General Hospital (1937-1959) . JAMA . 1962;180:122-126.Crossref 12. Bradley EL III, Isaacs J. Appendiceal abscess revisited . Arch Surg . 1978;113:130-132.Crossref 13. David IB, Buck JR, Filler RM. Rational use of antibiotics for perforated appendicitis in childhood . J Pediatr Surg . 1982;17:494-500.Crossref 14. Cruse PJE. Wound infections: epidemiology and clinical characteristics . In: Howard RJ, Simmons RL, eds. Surgical Infectious Diseases . 2nd ed. East Norwalk, Conn: Appleton & Lange; 1988:319-329. 15. Heseltine PN, Yellin AE, Appleman MD, et al. Imipenem therapy for perforated and gangrenous appendicitis . Surg Gynecol Obstet . 1986;162:43-48.

Lowenfels, Albert B.;Wormser, Gary P.;Jain, Rajesh

doi: 10.1001/archsurg.1989.01410110038007pmid: 2818181

Abstract • To evaluate the occupational risk of human immunodeficiency virus (HIV) infection, we surveyed 202 surgeons working in the New York City metropolitan area. One hundred seventythree (86%) surgeons reported at least one puncture injury in the preceding year (median number, 2 per year; interquartile range, 1 to 4 per year). Seventy-six percent of the injuries occurred during surgery, and the median injury rate was 4.2 per 1000 operating room hours. Twenty-five percent of the surgeons sustained yearly injury rates of 9 or more per 1000 operating room hours, and these high rates were independent of sex, age, type of practice, operative work load, or hospital location. Fifty-three percent of all injuries involved the index finger of the nondominant hand. If the prevalence of HIV infection in surgical patients is 5%, then the estimated 30-year risk of HIV seroconversion is less than 1% for 50% of the group, 1% to 2% for 25% of the group, 2% to 6% for 15% of the surgeons, and greater than 6% for 10% of the surgeons. (Arch Surg. 1989;124:1284-1286) References 1. Marcus R, CDC Cooperative Needlestick Surveillance Group. Surveillance of health care workers exposed to blood from patients infected with the human immunodeficiency virus . N Engl J Med . 1988;319:1118-1123.Crossref 2. Centers for Disease Control. Human immunodeficiency virus infection in the United States: a review of current knowledge . MMWR . 1987;36( (suppl S6) ):35. 3. Kelen GD, Fritz S, Qaqish B, et al. Unrecognized human immunodeficiency virus infection in emergency department patients . N Engl J Med . 1988: 318:1645-1650.Crossref 4. Centers for Disease Control. Update: human immunodeficiency virus in health-care workers exposed to blood of infected patients . MMWR . 1987;36:285-289. 5. Wormser GP, Joline C, Sivak SL, Arlin ZA. Human immunodeficiency virus infections: considerations for health care workers . Bull NY Acad Med . 1988;64:203-215. 6. Klein RS, Phelan JA, Freeman K, Schable C, Friedland GH, Trieger N. Low occupational risk of human immunodeficiency virus infection among dental professionals . N Engl J Med . 1988;318:86-90.Crossref 7. Hochreiter MC, Barton LL. Epidemiology of needlestick injury in emergency medical service personnel . J Emerg Med . 1988;6:9-12.Crossref 8. Ruben FL, Norden CW, Rockwell K, Hruska E. Epidemiology of accidental puncture wounds in hospital workers . Am J Med Sci . 1983;286:26-30.Crossref 9. Gerberding JL, Bryant-LeBlanc CE, Nelson K, Moss AR, Osmand D, Chambers HF. Risk of transmitting the human immunodeficiency virus, cytomegalovirus, and hepatitis B virus to health care workers exposed to patients with AIDS and AIDS-related conditions . J Infect Dis . 1987:1:1-7.Crossref 10. Hamory BH. Underreporting of needlestick injuries in a university hospital . Am J Infect Control . 1983;11:174-177.Crossref

Mansour, George M. I.;Cucchiaro, Giovanni;Niotis, Manolis T.;Fetter, Bernard F.;Moore, Joseph;Rice, Reed R.;Branum, Gene D.;Meyers, William C.

doi: 10.1001/archsurg.1989.01410110041008pmid: 2818182

Abstract • The clinical and pathologic records of 12 patients with pancreatic lymphoma were reviewed retrospectively to determine distinguishing clinical features. Radiologically, all patients had large abdominal masses in the region of the pancreas. Preoperative percutaneous cytologic biopsy specimens failed to make the diagnosis, and two specimens were interpreted incorrectly as poorly differentiated adenocarcinoma. The diagnosis was difficult to make in two cases, even at laparotomy. Four patients underwent a biliary bypass, and two underwent a concomitant gastric or duodenal bypass. Two patients died postoperatively. Four patients responded well to chemotherapy and/or radiation therapy, and two did not have any recurrences at 3 and 7 years postoperatively. Although rare, lymphoma should be considered in patients with undiagnosed pancreatic masses. The diagnosis may only be made with appropriate preoperative or intraoperative suspicion, and treatment may be rewarding, particularly in comparison with pancreatic adenocarcinoma. (Arch Surg. 1989;124:1287-1289) References 1. Baylor, SM, Berg JW. Cross-classification of survival characteristics of 5000 cases of cancer of the pancreas . J Surg Oncol . 1973;5:335-358.Crossref 2. Coltman CA, Dahlberg S, Jones SE, et al. CHOP is curative in thirty percent of patients with diffuse large cell lymphoma: a twelve year Southwest Oncology Group follow-up . Proc Am Soc Clin Oncol . 1986;5:197-200. 3. Reed K, Vose PC, Jarstfer BS. Pancreatic cancer: 30 year review (1947 to 1977) . Am JSurg . 1979;138:929-933.Crossref 4. Hart MJ, White TT, Brown PC, Freeny PC. Potentially curable masses in the pancreas . Am J Surg . 1987;154:134-136.Crossref 5. Ward EM, Stephens DH, Sheedy PF. Computed tomographic characteristics of pancreatic carcinoma: an analysis of 100 cases . Radiographics . 1984;3:547-563.Crossref 6. Teefey SA, Stephens DH, Sheedy PF. CT appearance of primary pancreatic lymphoma . Gastrointest Radiol . 1986;11:41-43.Crossref 7. Ackerman NB, Aust JC, Bredenberg CE, Hanson VA, Rogers LS. Problems in differentiating between pancreatic lymphoma and anaplastic carcinoma and their management . Ann Surg . 1976;184:705-708.Crossref 8. Knowles DM. Lymphoid cell markers: their distribution and usefulness in the immunophenotypic analysis of lymphoid neoplasms . Am J Surg Pathol . 1985;9:85-108. 9. Picker LJ, Wiss LM, Medeiros LJ, Wood GS, Warnke RA. Immunophenotypic criteria for the diagnosis of non-Hodgkin's lymphoma . Am J Pathol . 1987;128:181-201.

Podzorski, Raymond P.;Herron, Michael J.;Fast, David J.;Nelson, Robert D.

doi: 10.1001/archsurg.1989.01410110044009pmid: 2684094

Abstract • Candida albicans cell wall mannan polysaccharide has an ability to negatively influence cell-mediated immune function. We have attempted to identify the mechanism of this phenomenon by testing the modulatory effects of isolated mannan and the chemical catabolites of mannan on cell-mediated immune function in vitro. We have determined that mannan isolated by complexation with cetyltrimethylammonium bromide (CTAB) is more antigenic than mannan isolated by precipitation with copper and that CTAB mannan does not inhibit lymphoproliferation stimulated by another antigen. We have also determined that ollgosaccharides of three sizes, derived by chemical catabolism of CTAB mannan, are not antigenic, but instead are immunoinhibitory. Immunoinhibition does not involve interference with the mitogenic activity of interleukin 2. A similar occurrence of oligosaccharides may be produced by catabolism of mannan in vivo as evidenced by the presence of oligosaccharides of similar size in cell-free supernatant fluids derived from mononuclear leukocytes incubated with tritiated mannan. We propose that catabolites of fungal mannan may contribute significantly to suppression of cell-mediated immunity in candidiasis. (Arch Surg. 1989;124:1290-1294) References 1. Stone HH, Kolb LD, Currie CA, Geheber CE, Cuzzell JZ. Candida sepsis: pathogenesis and principles of treatments . Ann Surg . 1974;179:697-710.Crossref 2. Solomkin JS, Flohr AM, Simmons RL. Candida infections in surgical patients . Ann Surg . 1982;195:177-185.Crossref 3. Burchard KW, Minor LB, Slotman GJ, Gann DS. Fungal sepsis in surgical patients . Arch Surg . 1983;118:217-221.Crossref 4. Dyess DL, Garrison RN, Fry GE. Candida sepsis . Arch Surg . 1985;120:345-348.Crossref 5. Strinden WD, Helgerson RB, Maki DG. Candida septic thrombosis ofthe central veins associated with central catheters . Ann Surg . 1985;202:653-658.Crossref 6. Paterson PY, Semo R, Blumenschein G, Swelstad J. Mucocutaneous candidiasis, anergy and a plasma inhibitor of cellular immunity: reversal after amphotericin B therapy . Clin Exp Immunol . 1971;9:595-602. 7. Twomey JJ, Waddell CC, Krantz R, O'Reilly R, L'Esperance P, Good RA. Chronic mucocutaneous candidiasis with macrophage dysfunction, a plasma inhibitor, and co-existent aplastic anemia . J Lab Clin Med . 1975;85:968-977. 8. Nelson RD, Herron MJ, McCormack RT, et al. Two mechanisms of inhibition of human lymphocyte proliferation by soluble yeast mannan polysaccharide . Infect Immun . 1984;43:1041-1046. 9. Fischer A, Ballet JJ, Griscelli C. Specific inhibition of the in vitro Candida-induced lymphocyte proliferation by polysaccharidic antigens present in the serum of patients with chronic mucocutaneous candidiasis . J Clin Invest . 1978;62:1005-1112.Crossref 10. Böyum A. Isolation of mononuclear cells and granulocytes from human blood . Scand J Clin Lab Invest . 1968;21( (suppl 97) ):77-89.Crossref 11. Fink G. The biochemical genetics of yeast . Methods Enzymol . 1970;17( (pt A) ):59-78. 12. Nakajima T, Ballou C. Characterization of the carbohydrate fragments obtained from Saccharomyces cerevisiae mannan by alkaline degradation . J Biol Chem . 1974;249:7679-7684. 13. Peat SW, Whelan WJ, Edwards TE. Polysaccharides of bakers' yeast: part IV: mannan . J Chem Soc London . 1961;1:29-34. 14. Kozourek J, Ballou C. Method for finger painting yeast cell wall mannans . J Bacteriol . 1969;100:1175-1181. 15. Dubois M, Gilles KA, Hamilton JK, Rebers PA, Smith F. Colorimetric method for determination of sugars and related substances . Anal Chem . 1956;28:350-356.Crossref 16. Lipsky PE. Modulation of human antibody production in vitro by Dpenicillamine and CuSO4: inhibitor of helper T cell function . J Rheumatol . 1981;7( (suppl) ):69-73. 17. Smith KA, Lachman LB, Oppenheim JJ, Favata MF. The functional relationship of the interleukins . J Exp Med . 1980;151:1551-1556.Crossref 18. Smith KA. Interleukin 2: inception, impact and implications . Science . 1988;240:1169-1176.Crossref 19. Zoschke DC, Staite ND. Suppression of human lymphocyte proliferation by activated neutrophils or H2O2: surviving cells have an altered T-helper/T=suppressor ratio and an increased resistance to secondary oxidant exposure . Clin Immunol Immunopathol . 1987;42:160-170.Crossref 20. Haurowitz F. Immunochemistry and the Biosynthesis of Antibodies . New York, NY: Interscience; 1968. 21. Muchmore AV, Decker JM, Blaese RM, Nilsson B. Purification and characterization of a mannose-containing disaccharide obtained from human pregnancy urine: a new immunoregulatory saccharide . J Exp Med . 1984;160:1672-1685.Crossref 22. Ballou C. Structure and biosynthesis of the mannan component of the yeast cell envelope . Adv Microb Physiol . 1976;14:93-158.

Oría, Alejandro;Alvarez, Juan;Chiappetta, Luis;Fontana, Juan J.;Iovaldi, Mario;Paladino, Alberto;Bianchi, Ricardo;Frider, Bernardo

doi: 10.1001/archsurg.1989.01410110049010pmid: 2818183

Abstract • Stool screening for gallstones and ultrasound monitoring of diameter changes of the biliary and pancreatic duct were performed in 129 patients with choledocholithiasis. Gallstone migration was found in 44 patients, all of whom were operated on electively. At surgery, acute pancreatic lesions were found in 16 patients; in the remaining 28 there was no evidence of pancreatic inflammation. There were no significant differences among patients in both groups regarding sex, age, stone size, shape or number found in stools, interval between admission and migration, or the presence of a dilated pancreatic duct before migration. Pancreatic duct reflux, however, was significantly more frequent in cholangiograms of patients with acute pancreatitis, implying that a common channel may be a major factor relating to acute pancreatitis in patients with migrating gallstones. (Arch Surg. 1989;124:1295-1296) References 1. Houssin D, Castaing D, Lemoine J, Bismuth H. Microlithiasis of the gallbladder . Surg Gynecol Obstet . 1983;157:20-24. 2. McMahon MJ, Shefta JR. Physical characteristics of gallstones and the calibre of the cystic duct in patients with acute pancreatitis . Br J Surg . 1980;67:6-9.Crossref 3. Armstrong CP, Taylor TV, Jeacock J, Lucas S. The biliary tract in patients with acute gallstone pancreatitis . Br J Surg . 1985;72:551-555.Crossref 4. Kelly TR. Gallstone pancreatitis: local predisposing factors . Ann Surg . 1984;200:479-485.Crossref 5. McMahon MJ, Playforth MJ, Booth EW. Identification of risk factors for acute pancreatitis from routine radiological investigation of the biliary tract . Br J Surg . 1981;68:465-467.Crossref 6. Armstrong CP, Taylor TV. Pancreatic-duct reflux and acute gallstone pancreatitis . Ann Surg . 1986;204:59-64.Crossref 7. Jones BA, Salsberg BB, Mehta MH, Bohnen JMA. Common pancreaticobiliary channels and their relationship to gallstone size in gallstone pancreatitis . Ann Surg . 1987;205:123-125.Crossref 8. Cuschieri A, Cumming JGR, Wood RAB, Baker PR. Evidence for sphincter dysfunction in patients with gallstone associated pancreatitis: effect of ceruletide in patients undergoing cholecystectomy for gallbladder disease and gallstone associated pancreatitis . Br J Surg . 1984;71:885-888.Crossref 9. Acosta JM, Pellegrini CA, Skinner DB. Etiology and pathogenesis of acute biliary pancreatitis . Surgery . 1980;88:118-125. 10. Kelly TR. Gallstone pancreatitis: pathophysiology . Surgery . 1976; 80:488-492. 11. Oría A, Frider B, Alvarez J, Chiappetta L, Souto N, Fontana JJ. Biliary and pancreatic obstruction during gallstone migration . Int J Pancreatol . 1988;3:157-164. 12. Acosta JM, Rossi R, Ledesma CL. The usefulness of stool screening for diagnosing cholelithiasis in acute pancreatitis: a description of the technique . Dig Dis Sci . 1977;22:168-172.Crossref 13. Warshaw AL, Simeone JF, Shapiro RH, Hedberg SE, Mueller PR, Ferrucci JT. Objective evaluation of ampullary stenosis with ultrasonography and pancreatic stimulation . Am J Surg . 1985;149:65-72.Crossref 14. Ranson JHC. The timing of biliary surgery in acute pancreatitis . Ann Surg . 1979;189:654-662.Crossref 15. Di Magno EB, Shorter RG, Taylor WF, Go VLW. Relationships between pancreaticobiliary ductal anatomy and pancreatic ductal and parenchymal histology . Cancer . 1982;49:361-368.Crossref 16. Berman LG, Prior JT, Abramow BM, Ziegler DD. A study of the pancreatic duct system in man by the use of vinyl acetate casts of postmortem preparations . Surg Gynecol Obstet . 1960;110:391-403. 17. Bergkvist A, Seldinger SL. Pancreatic reflux in operative cholangiography in relation to pre- and postoperative pancreatic affection . Acta Chir Scand . 1957;114:191-197. 18. Howell CW, Berger GB. Pancreatic duct filling during cholangiography . Gastroenterology . 1950;16:309-316. 19. Taylor TV, Rimmer S. Pancreatic duct reflux in patients with gallstone pancreatitis . Lancet . 1980;1:848-850.Crossref 20. Opie EL. The etiology of acute hemorragic pancreatitis . Bull Johns Hopkins Hosp . 1901;12:182-188.